Healthcare utilization during transition to adult care in patients with spina bifida A population-based, longitudinal study in Ontario, Canada.

INTRODUCTION: Individuals with spina bifida (SB) may experience negative health outcomes because of an informal transition from pediatric to adult care that results in using the emergency room (ER ) for non-acute health problems. METHODS: We conducted a retrospective, population-based cohort study of all people with SB in Ontario, Canada turning 18 years old between 2002 and 2011. These patients were followed for five years before and after age 18. Primary outcome was the annual rate of ER visits. Secondary outcomes included rates of hospitalization, surgery, primary care, and specialist outpatient care. We estimated the association between age and primary and secondary outcomes using negative binomial growth curve models, adjusting for patient-level baseline covariates. RESULTS: Among the 1215 individuals with SB, there was no trend of ER visits seen with increasing age (relative risk [RR ] 0.99, 95% confidence interval [CI] 0.98-1.02); however, there was a significant increase in the rate of ER visits associated with turning 18 years (RR 1.14, 95% CI 1.03-1.27). Turning 18 years old was also associated with a decreased rate of hospital admissions (RR 0.79, 95% CI 0.66-0.95) and no change in surgeries (RR 0.80, 95% CI 0.64-1.02). Visits to primary care physicians remained stable over the same period (RR 0.96, 95% CI 0.90-1.01), while visits to SB-focused specialists decreased after age 18 (RR 0.81, 95% CI 0.75-0.87). CONCLUSIONS: In patients with SB, the rate of ER visits increased significantly at 18 years old, while hospital admissions and specialist physician visits decreased at the same time. Models of transitional care can aim to reduce non-urgent ER visits and facilitate regular specialist care.

Do larger cuff sizes with artificial urinary sphincter placement increase the risk of leakage after placement?

INTRODUCTION: To determine whether larger artificial urinary sphincters (AUS) cuff sizes of ≥ 5.0 cm have an impact on urinary incontinence after AUS implantation as compared to cuff sizes ≤ 4.5 cm. MATERIALS AND METHODS: A retrospective chart review of AUS implants performed at our institution from 1991 to 2021. Medical records were reviewed for demographics including body mass index (BMI), cause of incontinence, pelvic radiation, valsalva leak point pressure (VLPP), degree of leakage preoperatively and at 1-year post-AUS surgery, AUS revisions, erosion rate and the need for adjunct medication postoperatively. RESULTS: A total of 110 patients were included in the analysis. Of these, 44 patients had an AUS cuff size of ≥ 5.0 cm and 66 patients had a cuff size ≤ 4.5 cm. After AUS implantation at 1 year both groups had a median pad use of 1 pad per day. Lastly, the erosion rate was higher in the ≤ 4.5 cm cuff group (7.7% vs. 2.4%) but this was not statically significant. In all cases (6 patients) of cuff erosion, each patient had been radiated. CONCLUSION: AUS cuff sizes of ≥ 5.0 cm do not appear to have a negative impact on the degree of incontinence at 1-year post AUS as compared to those with cuff sizes ≤ 4.5 cm. The erosion rate was higher in those with cuffs ≤ 4.5 cm but was not statistically significant. This would suggest that at AUS implantation, the surgeon should choose a larger cuff if there is any doubt especially in those with radiation.

Complications after surgery for benign prostatic enlargement: a population-based cohort study in Ontario, Canada.

OBJECTIVES: To examine the complication rates after benign prostatic enlargement (BPE) surgery and the effects of age, comorbidity and preoperative medical therapy. DESIGN: A retrospective, population-based cohort study using linked administrative data. SETTING: Ontario, Canada. PARTICIPANTS: 52 162 men≥66 years undergoing first BPE surgery between 1 January 2003 to 31 December 2014. INTERVENTION: Medical therapy preoperatively and surgery for BPE. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was overall 30-day postoperative complication rates. Secondary outcomes included BPE-specific event rates (bleeding, infection, obstruction, trauma) and non-BPE specific event rates (cardiovascular, pulmonary, thromboembolic and renal). Multivariable analysis examined the association between preoperative medical therapy and postoperative complication rates. RESULTS: The 30-day overall complication rate after BPE surgery was 2828 events/10 000 procedures and increased annually over the study period. Receipt of preoperative α-blocker monotherapy (relative rate (RR) 1.05; 95% CI 1.00 to 1.09; p=0.033) and antithrombotic medications (RR 1.27; 95% CI 1.22 to 1.31; p<0.0001) was associated with increased complication rates. Among the ≥80-year-old group, the rate of complications increased by 39% from 2003 to 2014 (RR 1.39; 95% CI 1.21 to 1.61; p<0.0001). The mean duration of medical and conservative management increased by a mean of 2.1 years between 2007 and 2014 (p<0.0001 for trend). CONCLUSIONS: Thirty-day complication rates after BPE surgery have increased annually between 2003 and 2014. Preoperative medical therapy with alpha blockers or antithrombotics was independently associated with higher rates of complications. Over this time, the duration of conservative therapy also increased.

A pilot randomized-controlled trial of the urodynamic efficacy of mirabegron for patients with neurogenic lower urinary tract dysfunction.

AIMS: To determine the effectiveness of mirabegron in patients with neurogenic lower urinary tract dysfunction. METHODS: Randomized, double-blind, placebo-controlled study. Canadian patients with spinal cord injury (SCI) or multiple sclerosis (MS) with urinary symptoms and incontinence were recruited. Patients were randomized to mirabegron 25 mg (or an identical placebo) for 2 weeks at which point a dose escalation to mirabegron 50 mg (or an identical placebo) was maintained for 8 weeks. Urodynamics were performed before and after treatment. The primary outcome measure was maximum cystometric capacity (MCC). Intention to treat analysis and ANCOVA models (with adjustment for baseline values) were used and marginal means (MM) are reported; P-value <0.05 was considered significant. RESULTS: Sixteen (9 SCI and 7 MS) patients were randomized to mirabegron and 16 (10 SCI and 6 MS) to placebo. At study completion, there was no significant difference in MCC between mirabegron and placebo (MM 305 vs 369 mL, P = 0.20). There was no significant difference in volume at first neurogenic detrusor overactivity (NDO, MM 167 vs 137 mL, P = 0.14) and peak pressure of NDO (MM 69 vs 82 cmH2 O, P = 0.25). There was no significant difference in pad weights or voiding diary parameters. There was a significantly lower symptom burden among those treated with mirabegron (total neurogenic bladder symptom score MM 29 vs 34, P = 0.047). CONCLUSIONS: Among patients with SCI or MS, we demonstrated non-significant trends towards improvement in some urodynamic parameters with mirabegron 50 mg compared to placebo, and a significantly lower neurogenic bladder symptom burden.

Complications and Interventions in Patients with an Artificial Urinary Sphincter: Long-Term Results.

PURPOSE: The artificial urinary sphincter is a common treatment of male urinary incontinence. We sought to characterize long-term rates of artificial urinary sphincter revision/removal and reimplantation, and associated risk factors. MATERIALS AND METHODS: We performed a population based, retrospective study using the Ontario Health Insurance Plan database of all male patients who underwent artificial urinary sphincter implantation from 1994 to 2013. Hospital, diagnostic and billing codes were used to identify patients. The Kaplan-Meier method and multivariable Cox proportional hazards models were applied to examine the cumulative incidence of artificial urinary sphincter reimplantation and revision/removal, and identify risk factors, respectively. RESULTS: A total of 1,632 male patients underwent initial implantation of an artificial urinary sphincter. The 10-year revision/removal and reimplantation rates were 34% and 27%, respectively. There was no difference between high and low volume hospitals or between community and academic hospitals in terms of revision/removal. A high level of comorbidity was associated with an increasing risk of removal/revision. The reimplantation rate was significantly lower in patients who underwent insertion at hospitals with the highest volume of surgery (HR 0.55, 95% CI 0.37-0.82, p <0.01). A high level of comorbidity was not associated with an increasing risk of reimplantation. Preimplantation radiotherapy was not significantly associated with the risk of reimplantation (p = 0.17) or revision/removal (p = 0.95). Other factors were not significantly associated with reimplantation or revision/removal. CONCLUSIONS: Most men who undergo artificial urinary sphincter placement still have a device without repeat surgery 10 years following insertion. Radiotherapy does not increase the risk of repeat surgery. A high level of comorbidity was associated with an increasing risk of removal/revision.

Anterior segment optical coherence tomography changes with introduction and discontinuation of tamsulosin.

PURPOSE: The aim of this study was to quantify changes and reversibility in pupil dilation and iris dilator muscle region thickness associated with introduction and subsequent discontinuation of tamsulosin in patients naïve to this drug with the aid of an anterior OCT system. METHODS: The study was carried out on 7 patients (14 eyes) naïve to tamsulosin and with benign prostatic hypertrophy (BHP). Measurements taken by Vistante OCT were done pre- and post-dilation of the following: pupil size, iris dilator muscle region (DMR) thickness, sphincter muscle region (SMR) thickness, and anterior chamber depth. These measurement were taken at Day 0 (tamsulosin naive), Day 30 (after one month of tamsulosin, the treatment period) and day 60 (after one month of no tamsulosin, the discontinuation period). RESULTS: Post-dilation pupil diameter significantly increased during the discontinuation period (P = 0.047). Iris DMR thickness measurements post-dilation significantly decreased during treatment (P = 0.00044), discontinuation (0.00011), and combined periods (P = 0.000050). Anterior chamber depth measurements in post-dilation were significantly decreased during treatment (P = 0.0016), discontinuation (P = 0.017), and combined periods (P = 0.00022). CONCLUSION: Tamsulosin discontinuation effectively increases dilated pupil size, a measure that has been inversely linked to IFIS incidence pre-operatively. Decreased DMR thickness in this short term likely illustrates changes aside from atrophy, such as vascular changes. Decreased anterior chamber depths suggest aqueous humor production is decreased as well.

Artificial urinary sphincter erosion after radical prostatectomy in patients treated with and without radiation.

INTRODUCTION: There has been increasing evidence supporting the use of adjuvant radiotherapy after radical prostatectomy (RP) for prostate cancer. Significant stress incontinence after RP is not uncommon and the artificial urinary sphincter (AUS) is the gold standard of treatment. Our objective was to assess if increased use of radiotherapy after RP has changed the rate of erosion and infection in the face of improvement in radiation technique and equipment in men who had an AUS implanted in the last 10 years. METHODS: We retrospectively examined 118 patients from December 2001 to January 2012 who underwent a RP with or without postoperative radiotherapy and subsequently had an AUS implanted. We divided the patients into two cohorts (Group 1: December 2001-December 2006 and Group 2: January 2007-January 2012). We reviewed all patient records for age, cuff size implanted, history of postoperative radiotherapy, previous incontinence surgery, revisions, and complications (erosion/infection). RESULTS: There were 36 and 82 patients in Groups 1 and 2, respectively. The mean age was similar between groups, 67 years both groups (p = 0.980). The number of patients treated with postoperative radiotherapy was similar between groups (36% vs. 32%, p = 0.640, respectively). There was no difference in the incidence of erosion or infection between Group 1 and 2 (p = 0.848 and p = 0.178, respectively). The overall relative risk (RR) of erosion was significantly higher in those who had radiotherapy compared to those who did not (RR 4.05, 95% confidence interval 1.1-15.3). CONCLUSIONS: Over the last 10 years, there has not been an increase in the number of patients receiving an AUS after RP and radiotherapy at our centre. During this time, the incidence of erosion and infection has not increased. However, our study reaffirms that the relative risk of erosion remains higher in patients who have had radiotherapy despite improvement in radiation treatment techniques and equipment.

Long-term complications in men who have early or late radiotherapy after radical prostatectomy.

INTRODUCTION: Choosing adjuvant radiotherapy (RT) or salvage RT after radical prostatectomy (RP) for locally advanced prostate cancer is controversial. Performing RT early after RP may increase the risk of urinary complications compared to RT performed later. We evaluated the urinary complication rates of men treated with surgery followed by early or late RT. METHODS: Using a retrospective chart review, we compared rates of urinary incontinence (UI), bladder neck contracture (BNC), or urethral stricture in men with prostate cancer treated with early RT (<6 months after RP) or late RT (≥6 months after RP), 3 years after RT. RESULTS: In total, 652 patients (between 2000 and 2007) underwent early RT (162, 24.8%) or late RT (490, 75.2%) after RP. The mean time to early RT was 3.6 months (range: 1-5 months) and to late RT was 30.1 months (range: 6-171 months). At 3 years post-RT, UI rates were similar in the early RT and the late RT groups (24.5% vs. 23.3%, respectively, p = 0.79). Prior to RT, 27/652 (4%) patients had a BNC and 11/652 (1.7%) had a urethral stricture, of which only 1 BNC persisted at 3 years post-RT. After RT, 17/652 (2.6%) BNC and 4/652 (0.6%) urethral stricture developed; of these, 6 BNC and 2 urethral strictures persisted at 3 years. CONCLUSION: Rates of UI, BNC, and urethral stricture were similar with early and late RT at 3 years post-RT. These findings suggest that the timing of RT after RP does not alter the incidences of these urinary complications and can aid in the decision-making process regarding adjuvant RT versus salvage RT.

Do patients know their nerve-sparing status after radical prostatectomy?

OBJECTIVE: To determine patients' knowledge regarding their nerve-sparing status (NSS) after radical prostatectomy (RP) and what factors during their clinical treatment are associated with this. METHODS: One hundred consecutive patients attending an erectile dysfunction clinic in Toronto, Canada, with a prior RP were surveyed from December 2010 to June 2011. Patients were questioned whether they had undergone a nerve-sparing procedure and, if so, whether it was unilateral or bilateral. Patients were assessed on both knowledge (known vs unknown) and accuracy (correct vs incorrect) regarding their NSS. Operative reports were used to determine the true NSS of each patient. RESULTS: Thirty-nine percent of patients had no knowledge of their NSS. Forty-five percent of patients were able to correctly identify their NSS, including only 19% of patients undergoing a non-nerve-sparing procedure. On univariate analysis, factors associated with patients correctly knowing their NSS were age, having a nerve-sparing strategy dictated in the preoperative clinic note, nerve sparing included in the surgical consent form, and type of nerve-sparing procedure performed. On multivariate analysis, planned nerve-sparing approach dictated in the preoperative note (odds ratio [OR], 4.86), nerve sparing included in surgical consent (OR, 3.76), time since surgery (OR, 0.99), and having a bilateral nerve-sparing procedure (OR, 5.91) were associated with correctly identifying one's NSS. CONCLUSION: After RP, a significant proportion of patients with erectile dysfunction have no knowledge of whether they underwent a nerve-sparing procedure. By discussing with patients the planned nerve-sparing technique preoperatively and counseling them on their NSS postoperatively, urologists may be able to improve on patient recollection of their NSS.

Striated muscle in the prostatic apex: does the amount in radical prostatectomy specimens predict postprostatectomy urinary incontinence?

OBJECTIVE: To investigate whether the amount of striated muscle (SM) removed with the apical aspect of the prostate at prostatectomy can be predictive of postprostatectomy urinary incontinence (UI). METHODS: The records of 61 consecutive patients seen in follow-up after prostatectomy were reviewed. Complete clinical data were collected. Two uropathologists reviewed the hematoxylin and eosin sections of the apical margin to semiquantitatively assess the amount of SM according to the following scheme: 0 = no SM, 1 = 1%-10% SM (of total tissue), 2 = 11%-30% SM, and 3 = >30% SM. Continence status was determined based on the last clinical visit, with UI considered as any reported leakage. RESULTS: Patients had a median age of 62 years at surgery (interquartile range, 58-66 years) and had a median follow-up after surgery of 100 weeks (interquartile range, 50-176 weeks). Both prostate weight and SM score (P = .045 for both) were statistically significant predictors of incontinence on multivariate analysis. The odds of a patient with an average SM score of ≥2 being incontinent was 11.7 times that of a patient with an average score of <2. Using an SM score of ≥2 had a specificity of 98% and a sensitivity of 19% for detecting incontinence in patients after radical prostatectomy. CONCLUSION: The amount of SM seen in the pathology specimen after radical prostatectomy has a significant effect on postoperative UI.

Human resource assessment of academic urology across Canada: What are the future job prospects?

INTRODUCTION: Our objective was to capture an overview of anticipated staffing needs at Canadian urology academic centres over the next 5 years to help guide and counsel urology residents in their respective programs. METHODS: A 30-question survey was sent by email to all chairmen of academic urology divisions/departments during fall 2012. The first part of the survey solicited basic demographic information regarding number of residents, number of fellows and fellowships, and number of attending staff and affiliated hospitals. The second part of the survey included detailed questions on the number and sub-specialty of urologists needed at each respective institution, as well as the appropriate year of recruitment. RESULTS: The response rate was 100%. There are 13 urology training programs across Canada located in 6 out of the 10 provinces. Robotic surgery is available at 9 out of the 13 centres. A total of 68 urologists need to be recruited by academic institutions throughout Canada within the next 5 years. The greatest need is for general urologists, with a total of 13 required. This is followed by 12 urologic oncologists needed, 11 female urology, 7 reconstructive urologists, 6 pediatric urologists, 6 endourologists, 5 transplant surgeons, 4 infertility/andrology, and 4 experts in advanced laparoscopy/robotics. There was no need for any urologic trauma surgeons in any academic institution surveyed. CONCLUSIONS: A total of 68 urologists need to be recruited into academic urology across Canada within the next 5 years. This crucial information can be used to help guide urology residents in choosing the most appropriate fellowship, in addition to providing them with an overview of future job prospects at academic institutions throughout the country.

Urologic medications and ophthalmologic side effects: a review.

Commonly prescribed urologic medications can have significant ophthalmologic side effects. The existing information can be conflicting. We looked at alpha-blockers and intraoperative floppy iris syndrome (IFIS), phosphodiesterase type 5 (PDE5) inhibitors and non-arteritic ischemic optic neuropathy (NAION) and lastly anticholinergic medications and glaucoma. There is no conclusive scientific data on what to do if the risk of urinary retention is low to moderate, however, we recommend that patients having cataract surgery should stop alpha-blocker medications preoperatively. If there is a high risk of urinary retention, the alpha-blocker should not be withheld, with the active involvement of the ophthalmologist. The role of using 5 alpha-reductase inhibitors (5ARIs) can be considered. There is no convincing evidence that PDE5 inhibitors cause non-arteritic anterior ischemic optic neuropathy (NAION), but patients should be advised of the possible risk of visual loss, especially in patients with risk factors of ischemic heart disease. Acute angle closure glaucoma (AACG or closed angle glaucoma) is very rarely caused by anticholinergic medications in patients with narrow angle anterior eye chambers. However, these medications are safe in patients with open angle glaucoma or treated closed angle glaucoma. Urologists should inquire about the patient's glaucoma history from his/her ophthalmologist before starting an anticholinergic medication.

Results of high intensity focused ultrasound treatment of prostate cancer: early Canadian experience at a single center.

INTRODUCTION: High intensity focused ultrasound (HIFU) is a non-invasive technique that uses focused ultrasound waves to ablate tissue. This retrospective study evaluates the early HIFU experience at a single Canadian center. MATERIALS AND METHODS: Ninety-five patients were treated between March 2006 and December 2007 using the Sonablate-500 device (Focus Surgery, Indianapolis, IN, USA). Follow up occurred at 3 month intervals and included serial prostate-specific antigen (PSA) measurements, assessments of erectile function and continence rates with the international index of erectile function (IIEF) and expanded prostate cancer index composite (EPIC) questionnaires respectively. Early and late complications were also studied. RESULTS: There were 95 patients treated by five urologists. The mean age of patients was 64 years (range 46-91). The majority of men treated had Gleason 6 (n = 53) or Gleason 7 (n = 35) disease. The remainder had Gleason 8 (n = 5) and Gleason 9 (n = 2) prostate cancer. Prostate volume in the pre-treatment group was 30.5 cc (range 14.4 cc-73 cc). Cytoreductive androgen deprivation therapy prior to treatment was administered to 10 men. Post-HIFU with a minimum 6 months follow up (mean 10.62 months), 2% (1/59) of men had de novo moderate to severe erectile dysfunction (IIEF ≤ 11). With a minimum of 6 months follow up (mean 8.85 months), 17% (7/41) of the men had significant incontinence according to their EPIC scores. Early complications included catheter-related problems (n = 10), retention (n = 16), and urosepsis (n = 1). Late complications included need for cystoscopy (n = 25), TURP (n = 6), VIU/dilatation for stricture or bladder neck contracture (n = 13) and self-catheterization (n = 1). Prostatorectal fistula occurred in one patient who had prior radiotherapy. Salvage HIFU following radiation failure was performed in seven men. Recurrence of cancer following HIFU was diagnosed in seven men. Salvage treatment included radical prostatectomy (n = 3), radiation therapy (n = 2), repeat HIFU (n = 1), hormone therapy (n = 1). CONCLUSIONS: In our early experience HIFU treatment for prostate cancer was associated with a moderate rate of complications and failure. Further studies are required to examine long term outcomes with HIFU.

Efficacy of botulinum toxin A injection for neurogenic detrusor overactivity and urinary incontinence: a randomized, double-blind trial.

PURPOSE: We determined the efficacy of onabotulinumtoxinA for neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis. MATERIALS AND METHODS: In a prospective, double-blind, multicenter study 57 patients 18 to 75 years old with neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis and urinary incontinence (defined as 1 or more occurrences daily) despite current antimuscarinic treatment were randomized to onabotulinumtoxinA 300 U (28) or placebo (29) via cystoscopic injection at 30 intradetrusor sites, sparing the trigone. Patients were offered open label onabotulinumtoxinA 300 U at week 36 and followed a further 6 months while 24 each in the treatment and placebo groups received open label therapy. The primary efficacy parameter was daily urinary incontinence frequency on 3-day voiding diary at week 6. Secondary parameters were changes in the International Consultation on Incontinence Questionnaire and the urinary incontinence quality of life scale at week 6. Diary and quality of life evaluations were also done after open label treatment. RESULTS: The mean daily frequency of urinary incontinence episodes was significantly lower for onabotulinumtoxinA than for placebo at week 6 (1.31 vs 4.76, p <0.0001), and for weeks 24 and 36. Improved urodynamic and quality of life parameters for treatment vs placebo were evident at week 6 and persisted to weeks 24 to 36. The most common adverse event in each group was urinary tract infection. CONCLUSIONS: In adults with antimuscarinic refractory neurogenic detrusor overactivity and multiple sclerosis onabotulinumtoxinA is well tolerated and provides clinically beneficial improvement for up to 9 months.

Durability of endourologic skills: two-year follow-up study.

PURPOSE: To assess the long-term durability of endourologic skills among urology trainees after an intensive technical skills training course. SUBJECTS AND METHODS: Seventeen urology residents participated in a 2-day ureteroscopy course at a surgical skills center. Residents performed rigid ureteroscopy and basket manipulation of a small midureteral stone. Performance was assessed immediately after the course and 1 year and 2 years after training. Residents prospectively tracked all ureteroscopic cases in which they were considered the primary surgeon (i.e., performed greater than 75% of the procedure). Performance was measured using a validated global rating score (GRS), checklist score (CLS), and time required to complete the task. RESULTS: Overall, GRS improved over the 2-year follow-up (P < 0.001), with most of the improvement occurring in the first year (P = 0.03). The CLS and time to complete the task did not change (P = 0.08 and 0.12, respectively). At the 2-year follow-up, the number of cases logged had no significant effect on performance. CONCLUSIONS: Ureteroscopy skills are retained and continue to improve 2 years after completing an intense training session that uses high-fidelity bench models. Ureteroscopic experience is important for the maintenance and development of skills, even though they appear to plateau after 1 year. This result may also reflect a ceiling effect of the assessment tools.

Long-term patient satisfaction following cadaveric pubovaginal sling incontinence surgery using the UDI and IIQ-7 questionnaires.

AIMS: The goal of any incontinence surgery is overall long-term patient satisfaction. The purpose of our study was to assess long-term patient satisfaction following cadaveric fascia lata pubovaginal sling surgery using the urogenital distress inventory (UDI) and the short form of the incontinence impact questionnaire (IIQ-7). MATERIALS AND METHODS: A total of 47 patients who underwent pubovaginal sling incontinence surgery with a minimum follow-up of 2 years were sent by mail the UDI (total score = 300) and the IIQ-7 (total score = 100). Thirty-seven responses (78.7%) were obtained, with a mean follow-up of 3.8 years (range 2.0-6.2). RESULTS: Of the 37 patients who responded, the mean UDI score was 75.8 and the mean IIQ-7 score was 21.4. There was no difference in the mean IIQ-7 score for patients with more than 4 years follow-up as compared to the entire group (28.8, P = 0.22). In contrast, the mean UDI score for patients with more than 4 years follow-up was greater compared to the entire group (99.1, P = 0.04). UDI subscale analysis revealed that patients mainly complained of both irritative and stress symptoms as opposed to obstructive/discomfort symptoms (P < 0.01). Patients with pre-operative mixed incontinence had greater mean UDI and IIQ-7 scores compared to patients with pre-operative pure stress incontinence (96.7 vs. 58.0, P = 0.04; 32.5 vs. 11.9, P = 0.03). CONCLUSIONS: Overall long-term scores assessing quality of life (IIQ-7) were good and those assessing symptom distress (UDI) were satisfactory following pubovaginal sling surgery. Patients with pre-operative mixed incontinence are at greatest risk for post-operative dissatisfaction.

Success of sildenafil for erectile dysfunction in men treated with brachytherapy or external beam radiation for prostate cancer.

PURPOSE: We undertook to determine if any significant differences in the efficacy of sildenafil citrate for erectile dysfunction (ED) exists between patients who have received external beam radiation or brachytherapy for prostate cancer. MATERIALS AND METHODS: Thirty-one patients who had received external beam radiation and nineteen patients who had received brachytherapy for prostate cancer and were subsequently treated with sildenafil citrate for post-irradiation ED comprised the patient population. A chart analysis was performed to determine either the presence or absence of concomitant risk factors for ED (coronary artery disease, diabetes, hypertension and smoking history) as well as age at radiation and time lapse between radiation completion and sildenafil citrate administration. Patients were then contacted to ascertain sildenafil citrate efficacy (defined as the continued use of sildenafil citrate), dosage used and medication tolerance. RESULTS: Continued use of sildenafil citrate was reported by 12/19 (63%) of the brachytherapy patients and 7/31 (22%) of the external beam radiation patients, a significant difference (P<0.007). Of those with continued use of sildenafil citrate, the patients who had undergone external beam radiation had a longer mean period of use (33.7 months) than those who had been treated with brachytherapy (14.3 months) (P=0.006). The mean elapsed time between completion of radiation and administration of sildenafil citrate was 7.6 months and 21.6 months for the brachytherapy and external beam radiation patients respectively (P=0.002). A significant difference in mean age existed between the patient groups, with the external beam radiation group being significantly older (69.8 years and 65.1 years respectively, P=0.007) at the time of sildenafil citrate administration. Of the risk factors for ED examined in each patient group, none were found to predict treatment failure with sildenafil citrate. Of the patients who did not experience success with sildenafil citrate, both groups used the medication for comparable periods of time. CONCLUSIONS: Sildenafil citrate improved ED in a significantly greater number of patients who had undergone brachytherapy over those who had received external beam radiation. However, the patients who had received external beam radiation were both older and experienced a longer lapse of time between completion of radiotherapy and administration of sildenafil citrate than the brachytherapy patient group. This may explain the poorer success in the external beam radiation patients. The success of sildenafil in both groups of patients was lower than has previously been reported.

The effect of bench model fidelity on endourological skills: a randomized controlled study.

PURPOSE: Complex skills, such as ureteroscopy and stone extraction, are increasingly taught to novice urology trainees using bench models in surgical skills laboratories. We determined whether hands-on training improved the performance of novices more than those taught only by a didactic session and whether there was a difference in the performance of subjects taught on a low versus a high fidelity model. MATERIALS AND METHODS: We randomized 40 final year medical students to a didactic session or 1 of 2 hands-on training groups involving low or high fidelity bench model practice. Training sessions were supervised by experienced endourologists. Testing involved removal of a mid ureteral stone using a semirigid ureteroscope and a basket. Blinded examiners tested subjects before and after training. Performance was measured by a global rating scale, checklist, pass rating and time needed to complete the task. RESULTS: There was a significant effect of hands-on training on endourological performance (p <0.01). With respect to bench model fidelity the low fidelity group did significantly better than the didactic group (p <0.05). However, no significant difference was found between the high and low fidelity groups (p >0.05). The low fidelity model cost Canadian $20 to produce, while the high fidelity model cost Canadian $3,700 to purchase. CONCLUSIONS: Hands-on training using bench models can be successful for teaching novices complex endourological skills. A low fidelity bench model is a more cost-effective means of teaching ureteroscopic skills to novices than a high fidelity model.